It's been a while since the last blog entry, but it doesn't mean nothing happened. With our syndicate group at Imperial, we invested a lot in conducting an analysis of the Chilean health system, and you may want to have a look at it. Later this year, I'll also release our analysis of the Clostridium difficile outbreaks at the Maidstone NHS Trust.
The holiday season was quite busy, as I got back to Canada to celebrate with family and friends and prepared for the exams period, and had to come back this week for family reasons.
But now everything has settled, and the positive of all this time spent in airports is that I gathered a lot of material to write about.
One of the articles I read is from SmartMoney, the Wall Street Journal Magazine. It discussed the marketing of branded pharmaceuticals : "Peddling pills", as they say. It got me back to my roots, and reminded me of the reflection group we once started during my medical training to discuss the impact of pharmaceutical marketing on medical practice. The "GRRIP", as we used to call it, for "groupe de reflection sur les relations avec l'industrie pharmaceutique(1)". The focus of the article is in the US, but similar conditions prevail in many industrialized countries such as Canada and the UK.
Of course, the drugs-sales reps are important in bridging a gap in medical education by providing data on the newest (and more expensive, branded) drugs. They also provide hands-on explanation and demonstration of their product, which can be important to build the physician confidence to discuss how-to-use issues with patient. For example, asthma drugs are often delivered by inhalers, which are different from one to another, and may require demonstrations not made available in the medical literature.
However, it is unclear that this information is delivered in an unbiased and cost-effective manner. In the absence of direct comparative data between 2 branded drugs(2), the choice of which medication will be prescribed often depends on personal beliefs. Although such beliefs usually have a scientific foundation, there is no clear rule, and it opens the door to choice based on the best commercial pitch(3).
The techniques and numbers involved are astonishing. Over their professional lifetime, some doctors will receive the equivalent of more than $US 1 million from pharmaceutical companies(4). Conferences, consulting fees, continuing medical education and research funding are all accepted ways of marketing drugs to doctors. Drug-sales reps also provide samples aimed at building brand recognition, and in the US also provide vouchers to reduce patients co-payments. Various gifts (branded pens, clocks, prescription pads, etc) are also offered.
The impact of such marketing efforts is well documented. Even though doctors believe they are not influenced(5), numerous studies have shown that marketing efforts produce their desired outcomes : increase the prescription of the marketed drug(6). Also, social psychologists have clearly shown that receiving small gifts from someone triggers the need to reciprocate(7). However, the extent to which pharmaceutical marketing penetrates medical practice is debated. One PhRMA(8) representative cited in the article pretend the drugs-sales reps have no influence on prescription behaviour. Doctors won't admit they are influenced by pharmaceutical marketing. Nevertheless, billions of dollars are invested in pharmaceutical marketing. If there is no impact, shareholders should worry that their capital is used for such an unrewarding activity... Moreover, many academic medical centers in the US now prohibit drug-sales reps access to clinical areas. And at least one group of physicians, No Free Lunch, has emerged to educate about the need for doctors to stay independent.
After considering SID previously, and now reviewing the almost universal endorsement by doctors of the pharmaceutical industry marketing techniques, at a time where health care spending is booming and the need for cost containment imperative, policy-makers will need to review the structure and nature of the incentive system in health care. Because the question is not whether "how we should stop doctors for being so selfish(9)", but how can we incentivize them effectively to reduce overall health care costs. And we should try to take into account the potential impact of any measure on future innovation. As research is costly and risky, we might end-up with reduced incentive to develop new drug-based treatments.
Notes
1-Group for reflection on the relations with the pharmaceutical industry
2-It is often the case that randomized controlled trials for the newest medications do not compare similar competitors, but the newest vs the oldest drugs.
3-Drug-sales reps commercial pitches are often anchored in scientific information. Pharmaceutical companies invest large sums in research with a marketing focus.
4-Ethical guidelines forbids the acceptance of cash from drug sales reps, and the pharmaceutical
5-Am J Med 2001;110:551
6-Chest 1992;102:270; JAMA 1994;271:684; JAMA 1997;278:1745; JAMA 2002;287:612;
7-Discussed in more details in the SmartMoney article
8-Pharmaceutical research and manufacturers of America; the pharmaceutical industry trade group has issued voluntary guidelines to minimize excesses.
9-Which they are not in general. They actually behave like most economical agents, being responsive to incentives.
This work by
Stéphane Lemire is licensed under a
Creative Commons Attribution-Non-Commercial-Share Alike 2.0 UK: England & Wales License.
